PEMERINTAH KABUPATEN TANAH DATAR

RUMAH SAKIT UMUM DAERAH

PROF. DR. M. ALI HANAFIAH SM BATUSANGKAR
JALAN BUNDO KANDUNG No.1 BATUSANGKAR
Telp/Faks (0752) 71008 Website www.rsud.tanahdatar.go.id
Email rsud.hanafiah@yahoo.com, rsud.hanafiah31@gmail.com

SURAT PENGANTAR HEMODIALISIS

(TRAVELING DIALISIS)

Nama Pasien
Ny. MARNIATI
Name
Tanggal Lahir Day of Birth 16-03-1953 (70th)
Alamat
Ampalu Kaciak, Lima Kaum Kab. Tanah Datar - SUMBAR
Recent Address
Diagnosis Diagnosis CKD Stage V On HD
Hemodialisis Terakhir/ Last
30 Januari 2024
Dialysis
Frekuensi Hemodialisis Number
2x/weeks
of runs per week
Mesin Hemodialisis Dialysis
Fresenius 4008S
machine
Dialyzer
F7HPS
Dialyzer
Jenis Dialisat
Bicarbonate
Composition of Dialysate
QB/QD
150-200 ml/min /500
Blood Flow Rate
Lama Hemodialisis Time
4,5 hours
Dialysis
Heparinisasi Heparinization Standard dosis
Akses Vaskular Blood access CDL
HbsAg Non reactive
Anti HCV Non reactive
Anti HIV Non reactive
Penyulit HD
Akses CDL Tidak Lancar
Complication with dialysis run
Berat Badan Kering (BBK)
Observasi
Patient’s dry weight
Tekanan Darah
130/80 mmHg , N : 80 x/i
Blood Pressure Status
Hasil Laboratorium
Laboratory Data
Transfusi Darah Terakhir Last
-
Blood Transfusion
Lain-lain Others -

Batusangkar, 2 Februari 2024

Dr. HADIANTO, Sp.PD FINASIM

SIP/10/Yankes/VI/2018